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Keratin pearls

"Under higher magnification, keratin or epithelial pearl structures forming concentric layers 0.5-2 mm in diameter were seen under squamous skin epithelial adhesions. Clitorodynia, although rare, often appears to be caused by a closed compartment syndrome of adjacent skin adhesions to the glans clitoris, leading to underlying unrecognized balanitis, keratin pearl formation and chronic pain. If the corona of the glans clitoris cannot be visualized despite vigorous retraction, a closed compartment form of treatable chronic clitoral pain should be suspected." Successful Management of Clitorodynia Closed Compartment Syndrome https://university.auanet.org/abstrac... "Clitoral adhesions occur when the clitoral prepuce adheres to the glans clitoris. This can lead to accumulation of desquamated epithelial cells under the prepuce, resulting in the formation of smegmatic pseudocysts and keratin pearls. A keratin pearl is a focus of central keratinization within concentric layers of squamous cells. Presence of these firm, millimeter-sized masses can lead to clitoral pain (similar to a grain of sand in the eye). Vulvar lichen sclerosus was noted in 17% (7/41) of patients, with an average age of 46 years (range 24-73 years). Seventy-six percent (31/41) of patients also had the diagnosis of overactive (hypertonic) pelvic floor muscle dysfunction (PFD), 25% (8/31) had pudendal neuralgia and 10% (3/31) had interstitial cystitis/painful bladder syndrome. Forty-six percent (19/41) of patients had provoked vestibulodynia (PVD) associated with a hormonal factor (hormonal contraceptive use, postpartum/breastfeeding, perimenopause, or menopause). Recurrent vulvar candidiasis or tinea cruris was noted in 5% of patients. Four patients (10%) presented with clitoral pain alone and were not found to have other identified genitopelvic pain conditions." https://doi.org/10.1016/j.jsxm.2022.0... "Physical examination consistent with clitoral adhesions is based on the inability to visualize the entire glans corona. In this closed compartment, the space underneath the adherent prepuce and clitoris can become irritated, erythematous, or infected and can result in sexual dysfunction. Risk factors included a history of sexual pain, yeast infection, urinary tract infection, blunt perineal or genital trauma, lichen sclerosus, low calculated free testosterone, and other sexual dysfunctions including persistent genital arousal disorder." Aerts L, Rubin RS, Randazzo M, Goldstein SW, Goldstein I. Retrospective Study of the Prevalence and Risk Factors of Clitoral Adhesions: Women's Health Providers Should Routinely Examine the Glans Clitoris. Sex Med. 2018 Jun;6(2):115-122. doi: 10.1016/j.esxm.2018.01.003. Epub 2018 Mar 17. PMID: 29559206; PMCID: PMC5960030. https://pubmed.ncbi.nlm.nih.gov/29559... "Chronic inflammatory dermatosis along with post-menopausal atrophy of the vulva and obstetrical traumas can cause clitoral phimosis, thereby compromising its function." Aboud C, Cristinelli S, Roccaro G, Meningaud JP, Hersant B. Surgical treatment of clitoral phimosis. J Gynecol Obstet Hum Reprod. 2021 Jun;50(6):101919. doi: 10.1016/j.jogoh.2020.101919. Epub 2020 Sep 21. PMID: 32971308. https://pubmed.ncbi.nlm.nih.gov/32971... "Keratin pearls are intraepithelial accumulations of squamous cells and debris that can be an etiology of vulvovaginal irritation in pediatric patients and are often associated with clitoral adhesions. Keratin pearls can form when the overlying clitoral epithelium becomes blocked by clitoral adhesions.“ Bragiel RM, Umasankar N, Burgis JT, Tomlin KV. Treatment of Clitoral Keratin Pearls with Topical Estrogen Cream: Case Report. J Pediatr Adolesc Gynecol. 2023 Jun;36(3):321-323. doi: 10.1016/j.jpag.2022.10.002. Epub 2022 Oct 7. PMID: 36209998. https://pubmed.ncbi.nlm.nih.gov/36209... J Krapf, I Kopits, J Holloway, L Starsiak, S Lorenzini, A Goldstein, (135) Keratin Pearl Excision for Clitorodynia and Female Sexual Dysfunction, The Journal of Sexual Medicine, Volume 20, Issue Supplement_1, May 2023, qdad060.130, https://doi.org/10.1093/jsxmed/qdad06... Number and percentage of participants menopausal 7 (17%) History of hormonal birth control use 30 (73%) History of UTIs 24 (59%) History of yeast infections 23 (56%) Diagnosis of lichen sclerosus 5 (12%) History of blunt perineal/genital trauma 1 (2%) Diagnosis of endometriosis 2 (5%) Diagnosis of persistent genital arousal syndrome/genitopelvic dysesthesia (PGAD/GPD) 4 (10%) Diagnosis of vulvodynia/vestibulodynia 18 (44%) Myers MC, Romanello JP, Nico E, Marantidis J, Rowen TS, Sussman RD, Rubin RS. A Retrospective Case Series on Patient Satisfaction and Efficacy of Non-Surgical Lysis of Clitoral Adhesions. J Sex Med. 2022 Sep;19(9):1412-1420. doi: 10.1016/j.jsxm.2022.06.011. Epub 2022 Jul 20. PMID: 35869023. https://pubmed.ncbi.nlm.nih.gov/35869...